Journal of Integrative Medicine xxx (xxxx) xxx

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Journal of Integrative Medicine

journal homepage: www.jcimjournal.com/jim
www.journals.elsevier.com/journal-of-integrative-medicine

Original Research Article

Effects of lavender and Citrus aurantium on pain of conscious intensive

care unit patients: A parallel randomized placebo-controlled trial
Zahra Karimzadeh a, Mansooreh Azizzadeh Forouzi b, Haleh Tajadini c, Mehdi Ahmadinejad d, Callista Roy e,
Mahlagha Dehghan f,⇑
a
Department of Critical Care Nursing, Razi Faculty of Nursing and Midwifery, Kerman University of Medical Sciences, Kerman 7616913555, Iran
b
Neuroscience Research Center, Institute of Neuropharmacology, Kerman University of Medical Sciences, Kerman 7616913555, Iran
c
Department of Traditional Medicine, Faculty of Traditional Medicine, Kerman University of Medical Sciences, Kerman 7616913555, Iran
d
Department of Critical Care Medicine, Kerman University of Medical Sciences, Kerman 7616913555, Iran
e
Department of Nursing, Mount Saint Mary’s University, Los Angeles, CA 90049, United States
f
Nursing Research Center, Kerman University of Medical Sciences, Kerman 7616913555, Iran

a r t i c l e i n f o a b s t r a c t

Article history: Background: Conscious patients admitted to intensive care units (ICUs) suffer from pain for various rea-
Received 9 September 2020 sons, which can affect their recovery process.
Accepted 29 December 2020 Objective: The present study compared the effects of aromatherapy with Citrus aurantium and lavender
Available online xxxx
essential oils against placebo for reducing pain in conscious intensive care patients.
Design, setting, participants and interventions: This study was a parallel randomized placebo-controlled
Keywords: trial. The ICUs of two educational hospitals in Kerman in Southeastern Iran were the study setting.
Pain
One hundred and fifty conscious intensive care patients were randomly divided into three groups using
Lavender
Citrus aurantium
a stratified block randomization method. Two groups received aromatherapy with essential oils: one with
Intensive care lavender and the other with C. aurantium; these patients received a 30-minute therapy session using their
Aromatherapy assigned essential oil on the second day of their intensive care stay. The placebo group used 5 drops of
normal saline instead of essential oil during their session.
Main outcome measures: Patient’s pain was assessed using a visual analog scale before the aromatherapy
intervention, as well as immediately after and one and three hours after intervention.
Results: The mean pain score of the lavender group was 40.01 before the aromatherapy intervention and
fell to 39.40, 30.60 and 23.68 immediately after the intervention, and at hour one and three post-
intervention, respectively. The mean pain score of the C. aurantium group was 45.48 before the interven-
tion and was reduced to 32.34 at three hours after the intervention. The mean pain of the placebo group
decreased from 42.80 before the intervention to 35.20 at three hours after the intervention. Pain scores of
all groups decreased during the study (P < 0.001). The mean pain of the lavender group was significantly
lower than that of the placebo group at three hours after the intervention.
Conclusion: The results of this study showed that aromatherapy with lavender essential oil reduced pain
in conscious ICU patients. Our data could not justify the use of C. aurantium for reducing pain in this pop-
ulation.
Trial registration: No. IRCT20170116031972N9 (https://en.irct.ir/trial/40827).

Please cite this article as: Karimzadeh Z, Azizzadeh Forouzi M, Tajadini H, Ahmadinejad M, Roy C, Deh-
ghan M. Effects of lavender and Citrus aurantium on pain of conscious intensive care unit patients: A par-
allel randomized placebo-controlled trial. J Integr Med. 2021; xx(x): xxx–xxx
Ó 2021 Shanghai Changhai Hospital Published by Elsevier B.V. All rights reserved.

1. Introduction

Many people are admitted to intensive care units (ICUs) for var-
⇑ Corresponding author.
ious reasons. Patients admitted to ICUs, especially conscious
patients, are subject to stressful conditions and experience varying
E-mail address: m_dehghan@kmu.ac.ir (M. Dehghan).

https://doi.org/10.1016/j.joim.2021.01.006
2095-4964/Ó 2021 Shanghai Changhai Hospital Published by Elsevier B.V. All rights reserved.

Please cite this article as: Z. Karimzadeh, M. Azizzadeh Forouzi, H. Tajadini et al., Effects of lavender and Citrus aurantium on pain of conscious intensive
care unit patients: A parallel randomized placebo-controlled trial, Journal of Integrative Medicine, https://doi.org/10.1016/j.joim.2021.01.006
Z. Karimzadeh, M. Azizzadeh Forouzi, H. Tajadini et al.
levels of pain. Most patients in ICUs have life-threatening condi-
tions, which worsen their pains [1]. Pain is common in conscious
ICU patients, but it remains a medical problem, despite new
advances in its control. Pain is an unpleasant experience associated
with actual or potential tissue damage. About 64% of the patients
admitted to ICUs have experienced pain [2].
In ICUs, various procedures are performed on patients, and
invasive measures are among the factors that cause pain in the
ICUs [2,3]. Conscious ICU patients believed that some measures,
such as the presence of several patients with different conditions
in a single room, or admission of a newly ill patient, resuscitation
of patients, different visits of doctors, some nursing procedures,
various tools and equipment, noisy condition in the ward, non-
observance of the patient’s privacy, and sleep disorders caused
fear, anxiety, and pain in patients [4]. Some conscious patients
mentioned that nurses’ inattention to conscious patients, lack of
proper communication with conscious patients, and inattention
to the needs of conscious patients led to patient-nurse mistrust,
and thus patient confusion and severe pain [5].
Alleviating pain and anxiety for gravely ill patients in an ICU is a
clinical and humane priority but doing so may result in further
harm [6]. Improper pain management has negative clinical effects,
such as poor wound healing, insomnia, impaired mood, increased
risk of infection, hemodynamic instability, and increased risk of
ICU mortality [2,3,6]. Yet, appropriate pain control may decrease
delirium and agitation in ICU patients [6].
In general, pharmacological and non-pharmacological treat-
ments are two methods for pain reduction [7,8]. Medications often
have side effects, such as nausea, drowsiness, vomiting, allergic
reactions, shock, low blood pressure, and impaired vital signs,
including respiration and heart rates. In addition to numerous
physical and mental complications, they cause drug resistance
and impose high costs on the healthcare system [3,9]. Today, there
is a growing tendency to use non-pharmacological methods, such
as aromatherapy.
Aromatherapy, a type of complementary medicine, uses aro-
matic essential oils to prevent and treat diseases. Lavender is a
plant whose essential oil is used for aromatherapy. Its use in aro-
matherapy affects heart function, stimulates blood circulation,
and causes relaxation [10]. Lavender has antidepressant, antispas-
modic and antibacterial properties and is effective in treating
migraines and insomnia. Studies have also shown its effect in
reducing anxiety and pain [11–15]. Citrus aurantium is another
common essential oil in traditional medicine. C. aurantium flowers
are used to treat neurological diseases such as hysteria, seizure and
nerve weakness. In addition, this plant is considered to be sedative,
sleep-inducing, and appetite-inducing and to alleviate heart palpi-
tation [16].
Numerous studies have investigated the effects of lavender and
C. aurantium aromatherapy on pain, but few have investigated the
_
effects of these aromas on pain of conscious ICU patients. Ilter et al.
[12] showed that aromatherapy with lavender reduced catheter
pain in patients with cancer. Sharifipour et al. [17] and Namazi
et al. [18] showed that aromatherapy with C. aurantium reduced
post-cesarean and labor pains, respectively. However, some studies
have not confirmed the effectiveness of aromatherapy for pain
reduction. For example, Arjmand et al. [19] and Soltani et al. [20]
showed that aromatherapy with lavender had no effect on the sev-
ere pain in the early hours after discectomy and tonsillectomy.
It is clear that patients admitted to ICUs experience varying
degrees of pain [3,21]. Considering the importance of pain manage-
ment and the problems that can be caused by poorly managed
pain, appropriate strategies are critical for ICU patients [3]. Since
nurses have the highest contact with patients, they must use var-
ious non-pharmacological interventions, which, in addition to high
2
Journal of Integrative Medicine xxx (xxxx) xxx
availability, have lower costs and complications than pharmaco-
logical interventions for pain control [22]. In addition, among the
different types of aromatherapy [23] we chose inhalation aro-
matherapy, which is easier to apply in an ICU, where the patients
require a high level of care and have a wide range of healthcare
needs. The current study tested the hypothesis that aromatherapy
with lavender or C. aurantium is able to reduce the severity of pain
experienced by conscious ICU patients in the first three hours after
applying the aromatherapy intervention.
2. Methods
2.1. Study design and setting
This parallel randomized placebo-controlled trial was per-
formed on conscious patients admitted to the ICUs of Afzalipour
Hospital and Bahonar Hospital in Kerman in Southeastern Iran.
The study settings were Bahonar Hospital, the largest trauma cen-
ter in Southeastern Iran, with 4 ICUs and 12 active beds in each
unit, and Afzalipour Hospital, with three ICU divisions, including
general ICU (10 beds), surgical ICU (8 beds), and poisoning ICU (7
beds). Conscious patients admitted to these ICUs were the study
population.
2.2. Sample size and sampling
The study population was selected using a convenience sam-
pling method, and they were allocated into three groups using a
stratified block randomization method (stratum: gender, age ± 2,
and addiction). Labels A, B or C (A = lavender, B = placebo, and
C = C. aurantium) were assigned to the groups, and the block size
was 6. The randomization list was generated by using free online
software (https://www.sealedenvelope.com/simple-randomiser/
v1/lists). Mahlagha Dehghan generated the randomization list
and Zahra Karimzadeh enrolled the participants and assigned them
to the treatment groups.
Inclusion criteria included patients who were aged between 18
and 60 years [24] with the ability to read and write [20] having
normal sense of smell [24] and stable hemodynamic status [25].
Exclusion criteria were having received painkillers during the three
hours before the aromatherapy intervention [25] asthma or other
chronic respiratory problems, intubation during the last 24 h [16]
severe anxiety disorders based on a doctor’s diagnosis [26] eczema
or allergies to plants and citrus fruits [20] and the requirement of
sedatives during the aromatherapy intervention.
Power analysis calculations with G*Power software (version
3.1.9.2) indicated that for a power of 80%, significance threshold
of P = 0.05, and three treatment groups, 147 participants would
be needed to detect an effect size of 0.205.
2.3. Measurement
Two instruments were used to collect information in the pre-
sent study. The demographic and background information was col-
lected in a questionnaire that included age, gender, marital status,
type of disease, level of education, living place, history of asthma or
allergies, underlying diseases, vital signs, painkillers used for the
patient, patient’s diagnosis, sedatives received by the patient, his-
tory of admission to the ICU, history of stay at hospital, use or
non-use of sedatives and analgesics, dosage of sedatives and pain-
killers, and addiction.
The visual analog scale (VAS) is a 100-mm smooth line meant to
represent the level of pain a patient is experiencing. Ours was ori-
ented with no pain at the left origin of the line and the most severe
pain at the right terminus. The patient is asked to mark their pain
Z. Karimzadeh, M. Azizzadeh Forouzi, H. Tajadini et al.
on the line, and the distance in millimeters from the left origin is
used to represent their pain score. A mark from 0 to 2 mm indicates
no pain, between 2 and 40 mm indicates mild pain, between 40
and 70 mm indicates moderate pain, and greater than 70 mm
indicates severe pain. The test score can vary between 0 and 100.
Various studies have confirmed the psychometric properties of
this tool. The validity and reliability of VAS have been confirmed
in Iran [27].
2.4. Aromatherapy intervention and data collection
Patients were randomly divided into three groups, one received
aromatherapy with lavender essential oil, a second received aro-
matherapy with C. aurantium essential oil, and the third received
placebo. The intake questionnaire was completed before delivering
aromatherapy, and the VAS pain score was taken before, immedi-
ately after and one and three hours after the aromatherapy
intervention.
In addition to the routine care, normal saline (placebo), laven-
der essential oil or C. aurantium essential oil were used. First, the
VAS was completed during a patient interview. Then five drops
(0.3 mL) of normal saline, lavender essential oil (100% oil essence
made by Mashhad TabibDaru Company, Iran), or C. aurantium
essential oil (100% oil essence manufactured by Mashhad Tabib-
Daru Company, Iran) were applied to a gauze strip, which was
placed at a distance of 10 cm from the patient’s nose (the gauze
with normal saline was attached to the patient’s collar). The
patient was asked to inhale the aroma for 30 min. The VAS was
taken again at 1 and 3 hours after the aromatherapy treatment.
The aromatherapy intervention was performed on the second
day of the patient’s stay in the ICU. In addition, sampling was done
at 6–8 p.m. when the workload was less than other hours and the
patients were preparing for sleep. Some patients received seda-
tives, so their aromatherapy interventions were performed at least
3 h later.
In addition, Zahra Karimzadeh and her co-researcher performed
aromatherapy and collected data, so they were not blinded to the
treatment. Before data collection, Mahlagha Dehghan, experienced
in aromatherapy, trained Zahra Karimzadeh and her co-researcher
how to apply the inhalation aromatherapy and how to collect the
data.
2.5. Data analysis
IBM SPSS Statistics for Windows (version 24; IBM Corp.,
Armonk, NY, USA) was used for data analysis. Descriptive statistics
(frequency, percentage, mean and standard deviation) were used
to describe the demographic characteristics of patients, as well as
information about why they had been admitted to the ICU. Mean
and standard deviation were used to describe the pain score of
each treatment group. Chi-square, Fisher’s exact, one-way analysis
of variance (ANOVA) and Kruskal-Wallis tests were used to evalu-
ate the similarity of the three groups in terms of underlying vari-
ables. According to the parametric conditions (skewness,
kurtosis, Shapiro-wilk test and test of homogeneity of variances),
repeated measures ANOVA was used to compare the pain score
before, immediately after, and one and three hours after the aro-
matherapy intervention. In addition, Bonferroni post-hoc test was
used to compare pain mean differences among the groups at differ-
ent time points. A significance threshold of P < 0.05 was used.
2.6. Ethical consideration
The present study was done after obtaining the code of ethics
(IR.KMU.REC.1398.179) from Kerman University of Medical
Sciences and the code of clinical trial (No. IRCT20170116031972N9)
3
Journal of Integrative Medicine xxx (xxxx) xxx
from Iranian Registry of Clinical Trials, coordinating with the heads
of Afzalipour Hospital and Bahonar Hospital in Kerman and obtain-
ing informed consent from eligible patients. The purpose of this
study was explained to patients in the ICU. The patients were told
that the aromatherapy intervention would not interfere with their
treatment process and they could withdraw from the study at any
time. Patients in all three groups received routine care, and they
were protected against any physical, psychological, or social harm.
3. Results
In total, 189 patients were assessed for eligibility, of which, 169
eligible participants were allocated to the three study groups.
Finally, 150 participants finished the study (Fig. 1).
3.1. Baseline characteristics of the participants
The ages of the participants were (37.26 ± 12.72), (35.56 ± 11.
41) and (35.70 ± 10.58) years in the lavender, C. aurantium and pla-
cebo groups, respectively, not significantly different among the
study groups (P = 0.72 and F = 0.33). All the groups were homoge-
nous in terms of hospital type, level of education, living place, his-
tory of staying at hospital, diagnosis, history of addiction,
underlying disease, and vital signs (systolic blood pressure, dias-
tolic blood pressure, and oxygen saturation), except for heart rate
(Tables 1 and 2).
No significant difference was found among the groups in receiv-
ing sedatives three hours before the aromatherapy intervention. In
addition, no significant differences in medication types were
observed among the groups (P > 0.05); medications included anti-
convulsants, antidotes, antihypertensive, supplements, antibiotics,
corticosteroids and gastrointestinal medications.
3.2. Outcomes
The results of repeated measures ANOVA showed a significant
interaction between group  time (F = 5.35, P = 0.001) and time
(F = 93.73, P < 0.001). The mean pain in the lavender group was
40.01, 39.40, 30.60 and 23.68 before the aromatherapy interven-
tion, immediately after the intervention, and one and three hours
after the intervention, respectively. The mean pain in the C. auran-
tium group decreased from 45.48 before the intervention to 40.78
immediately after the intervention, 33.76 one hour after the inter-
vention and 32.34 three hours after the intervention. The mean
pain in the placebo group decreased from 42.80 before the inter-
vention to 41.60 immediately after the intervention, 36.40 one
hour after the intervention and 35.20 three hours after the inter-
vention. Pain scores in all three groups decreased during the study.
The results also showed no significant difference in the mean pain
at any time point, except for three hours after the intervention
(Table 3).
The mean pain score was not significantly different among the
three groups before the aromatherapy intervention, immediately
or one hour after the intervention. However, the mean pain in
the lavender group was significantly lower than that of the placebo
group at three hours after the intervention (P = 0.01). Although the
mean pain score in the lavender group was lower than that of the
C. aurantium group three hours after the intervention, it was not
statistically significant (P > 0.99, Table 4).
The results of the Bonferroni post-hoc tests for within group
comparisons showed that the mean pain score in the lavender
group was significantly reduced at three hours after the aro-
matherapy intervention, compared with before the intervention,
immediately and 1 hour after the intervention (P < 0.001). In addi-
tion, the pain score was significantly reduced at 1 hour after the
Z. Karimzadeh, M. Azizzadeh Forouzi, H. Tajadini et al. Journal of Integrative Medicine xxx (xxxx) xxx

Fig. 1. The flow diagram of the study.

Table 1
Demographic and clinical information of the research units in the three groups.

Variable Lavender (n = 50) Citrus aurantium (n = 50) Placebo (n = 50) Chi-square P-value
Frequency Percent Frequency Percent Frequency Percent
Hospital 5.08 0.08
Bahonar 24 48 34 68 33 66
Afzalipour 26 52 16 32 17 34
Gender
Male 30 60 30 60 30 60
Female 20 40 20 40 20 40
Education* 1.70 0.43
Middle/high school/diploma 31 77.5 28 65.1 26 74.3
Bachelor’s and higher 9 22.5 15 34.9 9 25.7
Living place* 1.96 0.38
Kerman 29 61.7 30 65.2 22 51.2
Other cities of Kerman Province 18 38.3 16 34.8 21 48.8
History of stay at hospital 1.23 0.54
Yes 24 52.2 28 59.6 20 64.5
No 22 47.8 19 40.4 11 35.5
Diagnosis 3.93 0.14
Trauma/surgery 16 34 22 48.9 14 29.8
Internal medicine 31 66 23 51.1 23 70.2
History of addiction 0.21 0.90
Yes 24 48 22 44 24 48
No 26 52 28 56 26 52
Underlying disease 0.29 0.87
Yes 7 14.3 6 13.6 8 82.6
No 42 85.7 38 86.4 38 17.4
*
In cases where the frequency in each group is less than 50, there was missing data.

intervention, compared with before and immediately after the the intervention, compared with before and immediately after the
intervention (P < 0.001). The mean pain score in the C. aurantium intervention (P < 0.001), but there was no significant difference
group was significantly reduced at three hours and one hour after between the VAS scores at three hours and one hour after the inter-
4
Z. Karimzadeh, M. Azizzadeh Forouzi, H. Tajadini et al. Journal of Integrative Medicine xxx (xxxx) xxx

Table 2
Mean and standard deviation of vital signs of the research units in three groups before the intervention.

Variable Lavender (n = 50) Citrus aurantium Placebo (n = 50) Statistical test P-value
(n = 50)
Mean SD Mean SD Mean SD
Heart rate 81.34 9.30 86.30 16.06 81.54 16.98 H = 6.29 0.04
Systolic blood pressure 124.92 16.61 125.30 16.39 120.42 13.76 F = 1.51 0.22
Diastolic blood pressure 73.08 12.28 76.74 10.45 73.28 10.72 F = 1.69 0.19
Oxygen saturation 96.72 2.23 96.20 4.59 97.08 2.05 F = 0.96 0.39

H: Kruskal-Wallis test; F: analysis of variance; SD: standard deviation.

Table 3
Mean and standard deviation of pain of the research units in the three groups.

Time Lavender (n = 50) Citrus aurantium (n = 50) Placebo (n = 50)

Mean SD Mean SD Mean SD
Before intervention 40.01 18.18 45.48 21.52 42.80 21.10
Immediately after the intervention 39.40 18.00 40.78 20.15 41.60 20.84
One hour after the intervention 30.60 17.19 33.76 17.52 36.40 19.67
Three hours after the intervention 23.68 19.26 32.34 18.53 35.20 21.12

SD: standard deviation.

Table 4
Comparing pain mean differences among the three groups at different time points.

Time Group Mean difference Standard error P-value*

Before intervention Lavender vs. Citrus aurantium –5.48 4.06 0.54
Lavender vs. placebo –2.80 4.06 > 0.99
C. aurantium vs. placebo 2.68 4.06 > 0.99
Immediately after the intervention Lavender vs. C. aurantium –1.38 3.94 > 0.99
Lavender vs. placebo –2.20 3.94 > 0.99
C. aurantium vs. placebo –0.82 3.94 > 0.99
One hour after the intervention Lavender vs. C. aurantium –3.16 3.63 > 0.99
Lavender vs. placebo –5.80 3.63 0.34
C. aurantium vs. placebo –2.64 3.63 > 0.99
Three hours after the intervention Lavender vs. C. aurantium –8.66 3.93 0.09
Lavender vs. placebo –11.52 3.93 0.01
C. aurantium vs. placebo –2.86 3.93 > 0.99
*
Repeated measures analysis of variance; adjustment for multiple comparisons: Bonferroni.

vention (P > 0.99). In addition, the mean pain score in the placebo
group was significantly reduced at three hours and one hour after
the intervention, compared with before and immediately after the
intervention (P < 0.001), but there was no significant difference in
pain score between three hours and one hour after the intervention
(P > 0.99).
3.3. Adverse events
Only one patient in the C. aurantium group was excluded from
the study because of a headache resulting from the inhalation of
C. aurantium essential oil. In addition, twelve participants (five in
the C. aurantium group and seven in the lavender group) could
not tolerate the smell.
4. Discussion
The present study showed that aromatherapy with lavender oil
was the most effective strategy for managing pain severity of con-
scious ICU patients, compared with placebo and C. aurantium. As no
study was performed on the pain levels of patients admitted to ICU
who did not participate in this study, data from other populations
were used to compare with the results.
Darzi et al. [13] and Abbasijahromi et al. [14] respectively
showed that aromatherapy with lavender significantly reduced
the pain intensity of patients who had had open-heart surgery
5
and gone through childbirth, compared with the placebo group.
_
Ilter et al. [12] and Kasar et al. [15] showed that inhalation of
lavender reduced pain after injection in patients with myofascial
pain syndrome, and reduced catheter pain in oncology patients.
The results of two systematic review studies also showed that aro-
matherapy with essential oils of lavender, orange, tea tree, lemon,
clary sage, and C. aurantium reduced hemodialysis complications,
including painful injection and headache during dialysis, chronic
knee pain, acute back and neck pain, labor and episiotomy pain,
and post-cesarean section pain [28,29]. In contrast, Amirhosseini
et al. [7] Arjmand et al. [19] and Soltani et al. [20] showed that
lavender aromatherapy was not effective for reducing pain inten-
sity after discectomy, tonsillectomy, and percutaneous
nephrolithotomy, respectively. Differences in the results of the
studies may be due to sample size, the study population, the inter-
vention, the use of essential oil, the number of essential oils and
the number of times the essential oil was used in the studies. In
addition, patients in our study did not undergo a surgery or inter-
ventional procedure; therefore, it is difficult to compare these
results to different studies, which were performed in different
patient populations.
Few studies have examined the effects of C. aurantium inhala-
tion on pain, compared to lavender. Contrary to the results of the
present study, Sharifipour et al. [17] and Namazi et al. [18] showed
that aromatherapy with C. aurantium reduced post-cesarean pain
and labor pain in nulliparous women. The reasons for the differ-
ence between the results of the present study and the mentioned
Z. Karimzadeh, M. Azizzadeh Forouzi, H. Tajadini et al.
study could be the sample size, the patient population, the fre-
quency of intervention, and the type of study. In the present work,
50 conscious ICU patients were examined in each group, while the
sample sizes in the studies of Sharifipour et al. [17] and Namazi
et al. [18] were relatively small; further, these studies used preg-
nant mothers admitted to the labor ward.
According to the results of the present study and mentioned
studies, it seems that aromatherapy with some essential oils has
a positive effect in reducing pain. In aromatherapy, the essential
oil reaches the part of the brain, the limbic system, that is respon-
sible for controlling emotions and reducing pain. The oils can also
have a physiological effect by penetrating the skin or lung tissue,
the blood circulation, and immune system. The oils enter the circu-
latory system through inhalation and can involve all body systems
in addition to the nervous system [6,23,30]. However, in the pre-
sent study, lavender inhalation was more effective than C. auran-
tium for reducing pain intensity. One reason may be their
different components. The major constituents of the lavender
essential oil are linalool and linalyl acetate, while the major con-
stituents of the C. aurantium essential oil are linalool and limonene
[28,29]. In addition, the duration of the intervention and the indi-
vidual feedback on each of the essential oils may be different.
Although the most common way to deal with pain is medications,
they have their own side effects, and it is better to use non-
pharmacological methods to control pain [5]. Essential oils are
inexpensive compared with most other medications. Further
research with larger sample sizes still needs to be done to explore
the role of aromatherapy in pain management.
The present study had some limitations. Since the ICU patients
were in poor condition, with many physical, mental and psycho-
logical changes, the patients themselves were reluctant to partici-
pate in the study. The high pain intensity of some patients required
that the ICU staff administer painkillers to reduce their suffering,
which affected our intervention process and caused dropouts.
Although 50 participants in each group completed the study, future
studies with larger sample size may better confirm the present
study results. In addition, in the present study, we used a single
session of aromatherapy; however, regular sessions may increase
the therapeutic effects of this treatment. Future studies are also
needed to assess the effectiveness of different essential oil doses
during inhalation aromatherapy.
5. Conclusion
The results of this study showed that aromatherapy with laven-
der essential oil reduced pain in conscious ICU patients. Since the
prevalence of pain is one of the major challenges in the ICU, health-
care providers must correctly identify and control patients’ pain.
Since aromatherapy, a type of complementary medicine, is a cheap,
easy, safe and non-invasive method, it may provide a non-
pharmaceutical option to reduce the pain of conscious patients in
the ICU. Owing to the fact that C. aurantium oil was not effective
for reducing patient’s pain in the present study, further studies
are needed to compare the efficacy of different essential oils and
help to improve the state of non-pharmaceutical acute pain man-
agement in the ICU setting.
Funding
No funding was received for this study.
Authors’ contribution
ZK, MAF, HT, MA, CR and MD designed the hypotheses and the
experiments, and ZK and MD performed the experiments and their
6
Journal of Integrative Medicine xxx (xxxx) xxx
analysis. ZK were responsible for data collection. ZK and MD partic-
ipated in data analysis. All authors participated in data interpreta-
tion and manuscript review and writing. MD were responsible for
preparation of the tables and figures. All authors contributed to the
scientific discussion of the data and of the manuscript.
Acknowledgment
We would thank all patients and the nursing staff of the ICUs for
their cooperation.
Conflicts of interest
The authors declare that there is no conflict of interest regard-
ing the publication of the paper.
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